Archive for January, 2015

Engineers and clinicians have cooperated to produce and test new classes of bioelectronics that have altered motor impairment that occurs after stroke. The rationale that increased intensity of training alters outcome derives from past clinical and preclinical work. Now several studies have demonstrated that interactive robotic devices are a potent tool for the therapist to deliver effortlessly, reproducible high intensity movement training. These robots are safe and can provide a platform so that recovery might be influenced by a combination of noninvasive novel treatment programs. Also, these robotic devices provide a continuous objective history of movement parameters that will open the horizon for their use in generating novel movement biomarkers to understand, predict and measure the influence of new treatments on motor outcome after neurological injury.

INTRODUCTION

The enormous personal and societal burden caused by diseases of the brain and spinal cord make imperative innovative attempts to reduce illness and alter permanent disability. Colleagues at MIT, HI Krebs and N Hogan, developed an array of interactive robotic devices that we have used to aid and abet treatment programs for neurological recovery of motor function of the limbs in patients who have had a stroke (1–4).

These interactive robots move a patient’s paretic arm and when the patient begins to move, these robots “get out of the way” so the patient can execute the movement with very little resistance from the device. With these robots, a therapist can generate training sessions that are intensity controlled (a single one-hour session requires over 1,000 to and fro movements of a limb segment). The robots are tireless agents that produce reliable, reproducible movement sequences. In addition, the controllers on these robotic devices can be tuned to individual patients so that the robot can present different physical challenges at the point when a patient is moving the robot arm, so that training can focus, for example, on the speed, trajectory (aiming) or force of a movement (5,6). The success of controlled multicenter randomized studies that used robotic protocols to improve the outcome of upper limb motor recovery in patients with chronic stroke prompted the American Heart Association to make robotic training standard care (5,7–9).

This work will review the continued relationship between rehabilitation robotics for the paretic upper extremity after chronic stroke and focus on frequent questions that arise in clinical practice: Can intensive training alter the dreaded “performance plateau”? Can the human–robot interaction be optimized for an individual patient? Can explicit training of the affected limb generalize to improvement on untrained motor tasks? Can the control group be trained in an intensive manner to mimic the robot training? Can the robot-derived measurements of movement provide an objective biomarker for studies of other treatments, especially new pharmacology for acute stroke? Can the robot training emerge as a platform for combination therapy?

Study Selection: Randomized and controlled trials up to 22nd June 2014 were included following pre-determined search and selection criteria.

Data Extraction: Data extraction occurred by two people independently using a pre-determined data collection form. Methodological quality was assessed by 2 reviewers using the PEDro methodological rating scale. Meta-analysis was conducted separately for the two research questions.

Data Synthesis: Eighteen trials (19 comparisons) were eligible for inclusion in the review. FES had a moderate effect on activity (SMD 0.40, 95% CI 0.09 to 0.72) compared with no or placebo intervention. FES had a moderate effect on activity (SMD 0.56, 95% CI 0.29 to 0.92) compared with training alone. When subgroup analyses were performed, FES had a large effect on upper limb activity (SMD 0.69, 95% CI 0.33 to 1.05) and a small effect on walking speed (MD 0.08 m/s, 95% CI 0.02 to 0.15) compared with any control.

Conclusions: FES appears to moderately improve activity compared with both no intervention and training alone. These findings suggest that FES should be used in stroke rehabilitation to improve the ability to perform activities.

Background: Despite the confirmed short-term effects of constraint-induced movement therapy, the long-term effects have not been sufficiently verified in terms of functional improvement of the affected arm.

Objective: To evaluate the long-term effects and relationship between arm use in activities of daily living and arm improvement with modified constraint-induced movement therapy in chronic stroke patients.

Conclusions: Among post-stroke patients with mild to moderate impairments of arm function, modified constraint-induced movement therapy without any other rehabilitation after intervention may improve arm function and increase arm use for 1 year. In addition, increasing arm use may represent an important factor in improving arm function, and vice versa.

Objective: To contrast changes in clinical and kinematic measures of upper extremity movement in response to virtually simulated and traditionally presented rehabilitation interventions in persons with upper extremity hemiparesis due to chronic stroke.

Design: Non-randomized controlled trial.

Setting: Ambulatory research facility.

Participants: Subjects were a volunteer sample of twenty one community-dwelling adults (mean age: 51 ± 12 years) with residual hemiparesis due to stroke more than 6 months before enrollment (mean: 74 ± 48 months), recruited at support groups. Partial range, against gravity shoulder movement and at least 10° of active finger extension were required for inclusion. All subjects completed the study without adverse events.

Interventions: A 2 weeks, 24-hour program of robotic/virtually simulated, arm and finger rehabilitation activities was compared to the same dose of traditionally presented arm and finger activities.

Results: Subjects in both groups demonstrated statistically significant improvements in the ability to interact with real-world objects as measured by the Wolf Motor Function Test (P = 0.01). The robotic/virtually simulated activity (VR) group but not the traditional, repetitive task practice (RTP) group demonstrated significant improvements in peak reaching velocity (P = 0.03) and finger extension excursion (P = 0.03). Both groups also demonstrated similar improvements in kinematic measures of reaching and grasping performance such as increased shoulder and elbow excursion along with decreased trunk excursion.

Conclusions: Kinematic measurements identified differing adaptations to training that clinical measurements did not. These adaptations were targeted in the design of four of the six simulations performed by the simulated activity group. Finer grained measures may be necessary to accurately depict the relative benefits of dose matched motor interventions.

Background: Bilateral training in poststroke upper-limb rehabilitation is based on the premise that simultaneous movements of the nonparetic upper limb facilitate performance and recovery of paretic upper-limb function through neural coupling effects.

Objective: To determine whether the degree of coupling between both hands is higher after bilateral than after unilateral training and control treatment.

Methods: In a single-blinded randomized controlled trial, we investigated rhythmic interlimb coordination after unilateral (mCIMT) and bilateral (mBATRAC) upper-limb training and a dose-matched control treatment (DMCT) in 60 patients suffering from stroke. To this end, we used a series of tasks to discern intended and unintended coupling effects between the hands. In addition, we investigated the control over the paretic hand as reflected by movement harmonicity and amplitude. All tasks were performed before and after a 6-week intervention period and at follow-up 6 weeks later.

Results: There were no significant between-group differences in change scores from baseline to postintervention and from postintervention to follow-up with regard to interlimb coupling. However, the mBATRAC group showed greater movement harmonicity and larger amplitudes with the paretic hand after training than the mCIMT and DMCT groups.

Conclusions: The degree of coupling between both hands was not significantly higher after bilateral than after unilateral training and control treatment. Although improvements in movement harmonicity and amplitude following mBATRAC may indicate a beneficial influence of the interlimb coupling, those effects were more likely due to the particular type of limb movements employed during this training protocol.

Purpose: Stroke upper limb impairment is associated with disability in activities of daily living. Gaming (Nintendo Wii) is being introduced to rehabilitation despite limited evidence regarding effectiveness. Little data exists on how gaming is implemented resulting in a lack of clinical information. We aimed to gather therapists’ opinions on gaming.

Methods: A survey was posted to therapists, identified from stroke services across Scotland. A second survey was posted to non-responders. Survey data were analysed using descriptive statistics and thematic coding.

Results: Surveys were sent to 127 therapists (70 stroke services) and returned by 88% (112/127). Gaming was used by 18% of therapists, 61% (68/112) stated they would use this intervention should equipment be available. The most commonly used device was Nintendo Wii (83% of therapists using gaming) for 30 min or less once or twice per week. Half of therapists (51%) reported observing at least one adverse event, such as fatigue, stiffness or pain. Gaming was reported to be enjoyable but therapists described barriers, which relate to time, space and cost.

Conclusions: Gaming is used by almost a fifth of therapists. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage.

Implications for Rehabilitation

Commercial gaming devices are reported to be used by 1/5th of therapists for stroke upper limb rehabilitation, 3/5ths would use gaming if available.

Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage.

Current use of gaming in practice may not be achieving intense and repetitive upper limb task-specific practice.

Lost & Found: What Brain Injury Survivors Want You to Know

Barbara J. Webster, Lash & Associates

I need a lot more rest than I used to. I’m not being lazy. I get physical fatigue as well as a “brain fatigue.” It is very difficult and tiring for my brain to think, process, and organize. Fatiguemakes it even harder to think.

My stamina fluctuates, even though I may look good or “all better” on the outside. Cognition is a fragile function for a brain injury survivor. Some days are better than others. Pushing too hard usually leads to setbacks, sometimes to illness.

Brain injury rehabilitation takes a very long time; it is usually measured in years. It continues long after formal rehabilitation has ended. Please resist expecting me to be who I was, even though I look better.

I am not being difficult if I resist social situations. Crowds, confusion, and loud sounds quickly overload my brain, it doesn’t filter sounds as well as it used to. Limiting my exposure is a coping strategy, not a behavioral problem.

If there is more than one person talking, I may seem uninterested in the conversation. That is because I have trouble following all the different “lines” of discussion. It is exhausting to keep trying to piece it all together. I’m not dumb or rude; my brain is getting overloaded!

If we are talking and I tell you that I need to stop, I need to stop NOW! And it is not because I’m avoiding the subject, it’s just that I need time to process our discussion and “take a break” from all the thinking. Later I will be able to rejoin the conversation and really be present for the subject and for you.

Try to notice the circumstances if a behavior problem arises. “Behavior problems” are often an indication of my inability to cope with a specific situation and not a mental health issue. I may be frustrated, in pain, overtired or there may be too much confusionor noise for my brain to filter.

Patience is the best gift you can give me. It allows me to work deliberately and at my own pace, allowing me to rebuild pathways in my brain. Rushing and multi-tasking inhibit cognition.

Please listen to me with patience. Try not to interrupt. Allow me to find my words and follow my thoughts. It will help me rebuild my language skills.

Please have patience with my memory. Know that not remembering does not mean that I don’t care.

Please don’t be condescending or talk to me like I am a child. I’m not stupid, my brain is injured and it doesn’t work as well as it used to. Try to think of me as if my brain were in a cast.

If I seem “rigid,” needing to do tasks the same way all the time; it is because I am retraining my brain. It’s like learning main roads before you can learn the shortcuts. Repeating tasks in the same sequence is a rehabilitation strategy.

If I seem “stuck,” my brain may be stuck in the processing of information. Coaching me, suggesting other options or asking what you can do to help may help me figure it out. Taking over and doing it for me will not be constructive and it will make me feel inadequate. (It may also be an indication that I need to take a break.)

You may not be able to help me do something if helping requires me to frequently interrupt what I am doing to give you directives. I work best on my own, one step at a time and at my own pace.

If I repeat actions, like checking to see if the doors are locked or the stove is turned off, it may seem like I have OCD — obsessive-compulsive disorder — but I may not. It may be that I am having trouble registering what I am doing in my brain. Repetitionsenhance memory. (It can also be a cue that I need to stop and rest.)

If I seem sensitive, it could be emotionallability as a result of the injury or it may be a reflection of the extraordinary effort it takes to do things now. Tasks that used to feel “automatic” and take minimal effort, now take much longer, require the implementation of numerous strategies and are huge accomplishments for me.

We need cheerleaders now, as we start over, just like children do when they are growing up. Please help me and encourage all efforts. Please don’t be negative or critical. I am doing the best I can.

Don’t confuse Hope for Denial. We are learning more and more about the amazing brain and there are remarkable stories about healing in the news every day. No one can know for certain what our potential is. We need Hope to be able to employ the many, many coping mechanisms, accommodations and strategies needed to navigate our new lives. Everything single thing in our lives is extraordinarily difficult for us now. It would be easy to give up without Hope.

Like this:

The Innovative YouGrabber Concept

YouGrabber supports patients with sensory-motor and cognitive impairments during rehabilitation. It provides interactive therapy exercises which focus on visuo-motor finger, hand and arm coordination. With this intensive training the patient’s therapy experience is improved, with the long-term goal of regaining independence in everyday life.

Complete Pair of Therapy Data Gloves

YouGrabber consists of a pair of therapy-optimized data gloves with integrated movement tracking that can be adjusted to almost all hand sizes and individual patient needs. The YouRehab training software provided with YouGrabber can be used on a normal computer for interactive training in a therapy practice, a clinic or at home.

Individual Adjustment

At the beginning of every training session the system is adjusted to the patient’s current abilities. Specific settings in each training application enable the training difficulty and content to be quickly and easily adapted to the patient’s abilities and therapy needs. The precise YouGrabber sensor technology enables immediate feedback during training and detailed documentation of training progress.

Brain Unnecessary to Control Mechanisms for Walking

PUBLISHED ON JANUARY 21, 2015

A chicken without a head running through a barnyard exemplifies how the spinal cord transmits motor signals after connection to the brain has been lost. Along these same lines, researchers in Italy recently identified the mechanisms the human spinal cord uses to control muscle activity even if neural pathways from the brain are physically interrupted.

A media release from Medical University of Vienna (MUV), where the researchers are based, states this is the first time the spinal cord activation patterns for walking have been decoded.

Paraplegics still have neural connections below the site of the injury, and these can trigger rhythmic movements in the legs. “Using statistical methods, we were able to identify a small number of basic patterns that underlie muscle activities in the legs and control periodic activation or deactivation of muscles to produce cyclical movements, such as those associated with walking. Just like a set of building blocks, the neural network in the spinal cord is able to combine these basic patterns flexibly to suit the motor requirement,” says study author Simon Danner, from the Center for Medical Physics and Biomedical Engineering of MedUni Vienna.

The results of the study appear in the journal Brain.

According to the MUV media release, the new findings that associate the basic patterns for triggering and coordinating muscle movements in the legs should provide a boost in creating novel approaches to rehabilitation that utilizes neural networks that remain functional after an event that results in paralysis. Most likely, those approaches would have used electrical stimulation, which is thought to be a potential therapeutic option in helping paraplegics partially regain lost rhythmic movements.

The method by which the neural networks would be stimulated depends upon the patient’s individual injury profile, and likely must be studied further. To help with this, the scientists at MedUni Vienna have developed a unique, noninvasive method for stimulating the spinal cord, which involves attaching electrodes to the surface of the skin. “This method allows easy access to the neural connections in the spinal cord below a spinal injury and can therefore be offered to those suffering from paraplegia without exposing them to any particular medical risks or stresses,” says Karen Minassian, senior author of the current publication.